motivational interviewing dr karen meechan [email protected] msc addictions 28/01/2014
TRANSCRIPT
Aims of Session
To
• Understand the spirit of MI
• Understand the fundamental skills required for MI
• Understand the four foundational processes of MI
Opening Exercise
• Think of something (that you don’t mind disclosing) that you feel in two minds about changing
• Split into pairs • Person 1: Share your dilemma with your
partner• Person 2: Argue strongly in favour of
change. Whatever the person says - do not deviate from this position
Issues Raised?
• Ambivalence about change is normal • Motivation fluctuates: it is dynamic• Motivation can be influenced by the way we are
talked to, and talk about it: it is interpersonal• ‘Resistance’ can be generated in the interaction• The Righting Reflex influences us as therapists• The more we say something the more we believe it
(Self-Perception Theory, Bem 1967)• Confidence to change is crucial (Self-Efficacy)
“People are generally better persuaded by the reasons which they themselves have discovered, than by those that have come into the minds of others”
Blaise Pascal – 17th century
Motivational Interviewing Origins
• Key people: William Miller and Steve Rollnick• USA: Culture of conflict in treatment• ‘Resistance’ attributed to the pathology of
patients, ie. “Addicts lack motivation and always deny the
severity of the problem”• William Miller was interested in how the
behaviour of counsellors might influence their clients’ behaviour
• Direct persuasion elicits resistance and denial can be experimentally manipulated
A Definition of MI
“A client-centred, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence”
Miller, W.R. and Rollnick, S. (2002). Motivational Interviewing – Preparing People for Change (2nd edition). NY: Guilford Press
“Having a quiet and constructive discussion about change in which the client drives the process as much as possible”
Rollnick, S. and Allison, J. (2004) Motivational Interviewing in N. Heather and T. Stockwell (Eds), Treatment and Prevention of Alcohol Problems. Chichester: Wiley
The Spirit of MIFundamental approach of MI
Collaboration. Counselling involves a partnership that honours the client’s expertise and perspectives. The counsellor provides an atmosphere that is conducive rather than coercive to change.
Evocation. The resources and motivation for change are presumed to reside within the client. Intrinsic motivation for change is enhanced by drawing on the client’s own perceptions, goals and values.
Autonomy. The counsellor affirms the client’s right and capacity for self direction and facilitates informed choice.
Compassion – MI-3
Mirror-image opposite approach to counselling
Confrontation. Counselling involves over-riding the client’s impaired perspectives by imposing awareness and acceptance of reality that the client cannot see or will not admit.
Education. The client is presumed to lack key knowledge, insight, and or/skills that are necessary for change to occur. The counsellor seeks to address these deficits by providing the requisite enlightenment.
Authority. The counsellor tells the client what he or she must do.
Summary of MI
• Not just a set of techniques. It is a clinical style – a way of being with clients
• Provides way of having conversations about behaviour change
• These conversations can be inherently ‘thorny’
• Aims to resolve ambivalence (which is normal not pathological)
• Minimises ‘resistance’• Builds client’s internal motivation for change
Motivation: “Ready, Willing and Able”
Willing: Importance of change - Why?
Able: Confidence for change - How?
Ready: A matterof priorities
Principles of MI
• Express empathy
• Roll with resistance
• Support self-efficacy
• Develop discrepancy
Four Foundational Processes in MI
The Relational Foundation
The Strategic Focus
The Transition to MI
The Bridge to ChangePlanning
Evoking
Guiding
Engaging
Engaging
Therapeutic Empathy
+
The OARS – Fundamental strategies used in MI (also basic conversation, communication and counselling skills)
• Ask Open Questions
• Affirm
• Listen Reflectively
• Summarise
Guiding
The strategic (directional) focus of MI• Finding a direction and developing changes or
goals• Agenda setting• Giving information and advice (ask-provide-
ask)MI is a guiding style, but not all guiding is MI
Engaging and Guiding are MI-consistentpractice, but not yet (in themselves) MI
Evoking
• The bridge to MI
• There is a clear change goal• Selective eliciting (OARS)
– Recognizing change talk– Eliciting change talk (e.g., selective questions)– Responding to change talk (e.g. selective
reflection)– Summarizing change talk– Using the importance and confidence ruler
Change Continuum (Prochaska and DiClemente, 1982)
(if you assume the client is more to the right then they are - you are likely to encounter ‘sustain talk’)
No change
Change
Precontemplation
Contemplation
Decision
Action
What is Unique to MI?
• Attuned to and guided by certain types of natural language (change talk)
• Intentional, differential evoking and strengthening of change talk
• Strategic-directional use of client-centered counseling methods (reflection, summary)
Applications in the Research
• Substance misuse, sexual health, dietary change, weight loss, voice therapy, gambling, physical activity promotion, medication adherence, diabetes, depression, anxiety, OCD, eating disorders, dual diagnosis, chronic leg ulceration, criminal justice, vascular risk, stroke rehabilitation, chronic pain, self-care, domestic violence, child health, oral health
• Whole issue of 2009 Journal Clinical Psychology (65, 11) about MI, including how it can be integrated with other psychotherapeutic approaches to treat mental health problems
Evidence Base• A lot of research (700 Psychinfo citations 2000-2009),
using variations of MI (eg. MET) and combined with other therapies, elements of MI only
• Applied to many clinical problems• Lundahl et al. (2010): Meta Analysis of MI. Significantly
better than TAU/no treatment, as good as other approaches (eg CBT, 12 step), shorter treatment, effects are durable over time, severity of problem does not affect effectiveness
• Ashton (2005): Consistently beneficial for less committed clients but can worsen outcomes to those already committed
• Moyers et al. (2009): Client change talk, once mobilised by therapist behaviour during MI sessions (eg. reflecting change talk when occurs) leads to reduced drinking
ReferencesAshton, M. (2005). The motivational hallo. Drug and Alcohol Findings, 13, 23-
30.Bem, D.J. (1967). Self-perception theory: an alternative interpretation of
cognitive dissonance phenomena. Psychological Review 73, 183-200.Lundahl, B.W, Kunz, C., Brownell, C. et al. (2010). A meta analysis of
motivational intervewing: twenty five years of empirical studies. Research on Social Work Practice, 20 (2), 37-160.
Miller W.R. and Rollnick, S. (2002). Motivational Interviewing: Preparing People to Change (2nd Ed). New York: Guilford Press.
Prochaska, J.O. and DiClemente, C.C. (1982). Transtheoretical therapy: Towards a more integrative model of change. Psychotherapy: Theory, Research and Practice, 19, 276-288.
Rollnick, S. and Allison, J. (2004) Motivational Interviewing in N. Heather and T. Stockwell (Eds), Treatment and Prevention of Alcohol Problems. Chichester: Wiley
Moyers, T. B., Martin, T., Houck, J.M. et al. (2009). From in-session behaviors to drinking outcomes: a causal chain for motivational interviewing. Journal of Consulting and Clinical Psychology, 77, 6, 1113-1124.
Further Reading
Website resource: www.motivationalinterview.org Miller, W. (1998) Why do people change addictive behaviour? The
1996 H. David Archibald Lecture Addiction 93 (2), 163- 172.Miller, W.R. and Rollnick, S. (2009) Ten things that motivational
interviewing is not. Behavioural and Cognitive Psychotherapy 37, 129-140.
Pilling, S., Hesketh, K. and Mitcheson, L. (2010). Routes to Recovery: Psychosocial Interventions fo Drug Misuse. London: BPS and NTA. http://www.nta.nhs.uk/uploads/psychosocial_toolkit_june10.pdf
Rollnick, S., Miller, W. and Butler, C. (2008). Motivational Interviewing in Health Care: Helping Patients Change Behaviour. London: Guildford Press.